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Younan G, Tsai S, Evans DB, Christians KK. A Novel Reconstruction Technique During Pancreaticoduodenectomy After Roux-En-Y Gastric Bypass: How I do It. J Gastrointest Surg 2017; 21:1186-1191. [PMID: 28447199 PMCID: PMC5486682 DOI: 10.1007/s11605-017-3405-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 03/16/2017] [Indexed: 01/31/2023]
Abstract
The altered anatomy in patients after bariatric surgery who have undergone a Roux-en-Y gastric bypass may pose a technical challenge for surgical removal of the pancreatic head. We treat patients with pancreas cancer with multimodality therapy in a neoadjuvant fashion followed by pancreaticoduodenectomy (PD). In patients with Roux-en-Y gastric bypass anatomy, the gastric remnant is preserved and used for pancreaticogastrostomy reconstruction and subsequently drained by the same jejunal limb used for the hepaticojejunostomy. This method of reconstruction takes advantage of the previous surgically altered anatomy and avoids the morbidity of a gastric remnant resection at the time of PD.
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Affiliation(s)
- George Younan
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Susan Tsai
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Douglas B. Evans
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
| | - Kathleen K. Christians
- 0000 0001 2111 8460grid.30760.32Pancreatic Cancer Program, Department of Surgery, Division of Surgical Oncology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226 USA
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202
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Richards MK, Goldin AB, Savinkina A, Doski J, Goldfarb M, Nuchtern J, Langer M, Beierle EA, Vasudevan S, Gow KW, Raval MV. The association between nephroblastoma-specific outcomes and high versus low volume treatment centers. J Pediatr Surg 2017; 52:104-108. [PMID: 27836364 DOI: 10.1016/j.jpedsurg.2016.10.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 10/20/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Though the volume-outcome relationship has been well-established in adults, low mortality rates and small sample sizes have precluded definitive demonstration in children. This study compares treatment-specific factors for children with nephroblastoma at high (HVC) versus low volume centers (LVC). METHODS We performed a retrospective cohort study comparing patients ≤18years with unilateral nephroblastoma treated at HVCs and LVCs using the National Cancer Data Base (1998-2012). Definitions of HVCs included performing above the median, the upper two quartiles, and the highest decile of nephroblastoma resections. Outcomes included nodal sampling, margin status, time to chemotherapy and radiation, and survival. Statistical analyses included χ2, t-tests, generalized linear, and Cox regression models (p<0.05). RESULTS Of 2911 patients from 210 centers, 1443 (49.6%) were treated at HVCs. There was no difference in frequency of preoperative biopsy or days to radiation (p>0.05). High volume centers were more likely to perform nodal sampling (RR 1.04, 95%CI 1.01-1.08) and had fewer days to chemotherapy (RR 0.80, 95%CI 0.69-0.93). Five-year survival was similar (HVC: 0.93, 95%CI 0.92-0.94; LVC: 0.93, 95%CI 0.91-0.94). CONCLUSIONS HVCs were more likely to perform nodal sampling and had fewer days to chemotherapy. There was no difference in days to radiation or survival between centers. LEVEL OF EVIDENCE Level II (retrospective prognosis study).
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Affiliation(s)
- Morgan K Richards
- University of Washington, Department of Surgery; Seattle Children's Hospital, Department of Thoracic and General Surgery.
| | - Adam B Goldin
- Seattle Children's Hospital, Department of Thoracic and General Surgery
| | | | - John Doski
- Methodist Children's Hospital of South Texas
| | | | | | | | | | | | - Kenneth W Gow
- Seattle Children's Hospital, Department of Thoracic and General Surgery
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203
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Frequency of medical malpractice claims: The effects of volumes and specialties. Soc Sci Med 2016; 170:152-160. [DOI: 10.1016/j.socscimed.2016.10.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 10/16/2016] [Accepted: 10/19/2016] [Indexed: 01/03/2023]
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204
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Cheng CW, Liu FC, Lin JR, Tsai YF, Chen HP, Yu HP. The Impact of Hospital/Surgeon Volume on Acute Renal Failure and Mortality in Liver Transplantation: A Nationwide Cohort Study. PLoS One 2016; 11:e0162992. [PMID: 27706183 PMCID: PMC5051740 DOI: 10.1371/journal.pone.0162992] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/31/2016] [Indexed: 12/13/2022] Open
Abstract
The aim of this study was to assess whether the case volume of surgeons and hospitals affects the rates of postoperative complications and survival after liver transplantation. This population-based retrospective cohort study included 2938 recipients of liver transplantation performed between 1998 and 2012, enrolled from the Taiwan National Health Insurance Research Database. They were divided into two groups, according to the cumulative case volume of their operating surgeons and the case volume of their hospitals. The duration of intensive care unit stay and post-transplantation hospitalization, postoperative complications, and mortality were analyzed. The results showed that, in the low and high case volume surgeons groups, respectively, acute renal failure occurred at the rate of 14.11% and 5.86% (p<0.0001), and the overall mortality rates were 19.61% and 12.44% (p<0.0001). In the low and high case volume hospital groups, respectively, acute renal failure occurred in 11% and 7.11% of the recipients (p = 0.0004), and the overall mortality was 18.44% and 12.86% (p<0.0001). These findings suggest that liver transplantation recipients operated on higher case volume surgeons or in higher case volume hospitals have a lower rate of acute renal failure and mortality.
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Affiliation(s)
- Chih-Wen Cheng
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Fu-Chao Liu
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Jr-Rung Lin
- Clinical Informatics and Medical Statistics Research Center and Graduate Institute of Clinical Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Yung-Fong Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Hsiu-Pin Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Huang-Ping Yu
- Department of Anesthesiology, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
- * E-mail:
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205
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Ertel AE, Wima K, Hoehn RS, Chang AL, Hohmann SF, Ahmad SA, Sussman JJ, Shah SA, Abbott DE. Variability in postoperative resource utilization after pancreaticoduodenectomy: Who is responsible. Surgery 2016; 160:1477-1484. [PMID: 27712874 DOI: 10.1016/j.surg.2016.08.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/14/2016] [Accepted: 08/18/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND We aimed to quantify and predict variability that exists in resource utilization after pancreaticoduodenectomy and determine how such variability impacts postoperative outcomes. METHODS The University HealthSystems Consortium database was queried for all pancreaticoduodenectomies performed between 2011-2013 (n = 9,737). A composite resource utilization score was created using z-scores of 8 clinically significant postoperative care delivery variables including number of laboratory tests, imaging tests, computed tomographic scans, days on antibiotics, anticoagulation, antiemetics, promotility agents, and total number of blood products transfused per patient. Logistic, Poisson, and gamma regression models were used to determine predictors of increased variability in care between patients. RESULTS Having a high (versus low) resource utilization score after pancreaticoduodenectomy correlated with increased duration of stay; (odds ratio 2.28), cost (odds ratio 1.89), readmission rate (odds ratio 1.46), and mortality (odds ratio 7.54). Patient-specific factors were the strongest predictors and included extreme severity of illness (odds ratio 114), major comorbidities/complications (odds ratio 5.99), and admission prior to procedure (odds ratio 2.72; all P < .01). Surgeon and center volume were not associated with resource utilization. CONCLUSION Public reporting of patient outcomes and resource utilization, invariably tied to reimbursement in the near future, should consider that much of the postoperative variability after complex pancreatic operation is related to patient-specific risk factors.
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Affiliation(s)
- Audrey E Ertel
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Koffi Wima
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Richard S Hoehn
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Alex L Chang
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | | | - Syed A Ahmad
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Jeffrey J Sussman
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Cincinnati Research in Outcomes and Safety in Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel E Abbott
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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206
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Rombouts SJ, Walma MS, Vogel JA, van Rijssen LB, Wilmink JW, Mohammad NH, van Santvoort HC, Molenaar IQ, Besselink MG. Systematic Review of Resection Rates and Clinical Outcomes After FOLFIRINOX-Based Treatment in Patients with Locally Advanced Pancreatic Cancer. Ann Surg Oncol 2016; 23:4352-4360. [PMID: 27370653 PMCID: PMC5090009 DOI: 10.1245/s10434-016-5373-2] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Indexed: 12/15/2022]
Abstract
Background FOLFIRINOX prolongs survival in patients with metastatic pancreatic cancer and may also benefit patients with locally advanced pancreatic cancer (LAPC). Furthermore, it may downstage a proportion of LAPC into (borderline) resectable disease, however data are lacking. This review assessed outcomes after FOLFIRINOX-based therapy in LAPC. Methods The PubMed, EMBASE and Cochrane library databases were systematically searched for studies published to 31 August 2015. Primary outcome was the (R0) resection rate. Results Fourteen studies involving 365 patients with LAPC were included; three studies administered a modified FOLFIRINOX regimen. Of all patients, 57 % (n = 208) received radiotherapy. The pooled resection rate was 28 % (n = 103, 77 % R0), with a perioperative mortality of 3 % (n = 2), and median overall survival ranged from 8.9 to 25.0 months. Survival data after resection were scarce, with only one study reporting a median overall survival of 24.9 months in 28 patients. A complete pathologic response was found in 6 of 85 (7 %) resected specimens. Dose reductions were described in up to 65 % of patients, grade 3–4 toxicity occurred in 23 % (n = 51) of patients, and 2 % (n = 5) had to discontinue treatment. Data of patients treated solely with FOLFIRINOX, without additional radiotherapy, were available from 292 patients: resection rate was 12 % (n = 29, 70 % R0), with 15.7 months median overall survival and 19 % (n = 34) grade 3–4 toxicity. Conclusions Outcomes after FOLFIRINOX-based therapy in patients with LAPC seem very promising but further prospective studies are needed, especially with regard to survival after resection.
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Affiliation(s)
- Steffi J Rombouts
- Department of Surgery, University Medical Centre Utrecht Cancer Center, Utrecht, The Netherlands
| | - Marieke S Walma
- Department of Surgery, University Medical Centre Utrecht Cancer Center, Utrecht, The Netherlands
| | - Jantien A Vogel
- Department of Surgery, G4-196, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Johanna W Wilmink
- Department of Medical Oncology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Centre Utrecht Cancer Center, Utrecht, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, G4-196, Academic Medical Centre, Amsterdam, The Netherlands.,Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Centre Utrecht Cancer Center, Utrecht, The Netherlands
| | - Marc G Besselink
- Department of Surgery, G4-196, Academic Medical Centre, Amsterdam, The Netherlands.
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